Healthcare Provider Details

I. General information

NPI: 1639155385
Provider Name (Legal Business Name): CANDIECE NICOLE MILLER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E MEMORIAL RD
OKLAHOMA CITY OK
73131-1253
US

IV. Provider business mailing address

1919 E MEMORIAL RD
OKLAHOMA CITY OK
73131-1253
US

V. Phone/Fax

Practice location:
  • Phone: 405-749-7099
  • Fax: 405-216-5872
Mailing address:
  • Phone: 405-749-7099
  • Fax: 405-216-5872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1167
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: